To China!

Leaving Monday. I'll write when we arrive.


Jewish geopolitics
Not paradoxical anymore.

I can't think of anything to blog. We're leaving for China next Monday, and I'm occupied with traveler's questions (will my bottles of Passover wine explode in my baggage? will my two-year-old daughter have to translate for us? will I learn to speak only a smattering of Mandarin, in a thick Fujianese accent?).

So I'll throw an article your way by someone who davens and teaches at my shul. I think it's very reminiscent of Michael Walzer's political philosophy.
Israel again [in the modern era] faces political decisions, such as to how to deal with other peoples and/or nations that critically affect their national security. Consider, for example, the following question: Is Israel obligated to construct the security fence, and/or otherwise to pursue policies, so as not to foreclose the possibility that a viable (and peaceful) Palestinian state can emerge in the West Bank? And, whether or not international law, or general moral principles applicable to Israel as a state, would so require, is there some, or any, particularly Jewish value that bears on this

[. . .]

[. . .] Israel’s claim is not that it itself is a just, liberal state. Rather, Israel’s claim is that a state fostering Judaism (but still protecting the basic rights of all citizens) islegitimate within the context of a pluralistic international order that includes both other states dedicated to pure neutral-liberalism, and other states dedicated to “decent” particularist visions, e.g., to Islam, or to Christianity.

Such a pluralistic vision of the place and role of Israel vis-à-vis other nations has, I submit, very deep Biblical roots. Thus the vision of the end of days at the conclusion of Isaiah Chapter 19 is not a vision of an end to all nationalisms, nor a vision of Israel dominating other nations, but rather a picture of Israel co-existing with Egypt and Assyria:

In that day, Israel shall be a third partner with Egypt and Assyria as a blessing on earth. For the Lord of Hosts will bless them, saying, “Blessed be my people Egypt, my handiwork Assyria, and my very own Israel.”


Do blacks, Hispanics, and the poor get poorer medical care?

The intuitive answer is yes, and in fact previous literature (see this paper, for example) seems to support this assertion. But a new article in the New England Journal of Medicine claims to show the opposite. Say the authors of the new article: "Previous studies have focused on a narrow set of quality indicators and conditions in selected populations and have had a limited ability to adjust for the range of factors associated with poorer quality. Few studies have examined quality across the continuum of care for multiple conditions."

The paper by Asch et al., then, seeks to estimate whether the care actually received by the subjects in their study population correspond to a set of indicators of ideal care. The indicator set is available here as a PDF, in a working paper from RAND (the authors' institution).

Surprisingly, the authors estimate that the population overall received 55 percent of recommend care -- that is, we're all not getting the care we should be. Even more surprising was the finding that quality of care varied only slightly among racial and socioeconomic groups.

The authors conclude, "Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care. "

This is probably the case. But their results should not be accepted uncritically, for two important reasons.

1. Abysmal response rate. The authors included in the study "all persons for whom [they] had at least one record (37 percent of the eligible sample). " Of course, the authors performed sensitivity analyses (in lay terms: estimating what difference the response rate might have had on the calculated results) and constructed models which controlled for non-response. They say, for example, "For nonresponse by blacks [in this study] to have produced the magnitude of disparities commonly found in previous studies, nonrespondent blacks would need to have had implausibly low (near zero) quality scores." Whether this is implausible is open to question, I think.

The study also excluded people who don't have a telephone and who saw no health-care provider during the previous two years. Obviously, these are the poorest of the poor.

2. Quality by what measure? The quality indicators used in this study come from a variety of sources: randomized trials together with consensus statements by professional societies. Furthermore, we don't know whether these quality indicators correspond to decreases in morbidity or mortality.

Despite these weaknesses, this is a highly important result. And I can comment, based on my limited personal experience, that it rings true. Errors are widespread. I have seen the poor get the same care as the very rich, and I have seen both failed by the system.
Doc, I'm breathing funny!
Funny peculiar, or funny ha-ha?

In this week's New England Journal, Rachel Sobel, a medical writer and fourth-year medical student at UCSF, has a thought-provoking piece about humor in the medical workplace. When young doctors loosen up in private, patients are often the butt of their jokes. This helps to shore up doctors' sanity in a stressful environment, but corrodes the dignity of the sick and the doctor-patient relationship.
The medical teams convened for a ritual snack break at 10:45 on a recent call night. We ate our ice cream in the far corner of the Moffiteria — as we affectionately call the cafeteria at UCSF's Moffit–Long Hospital — fueling up before the onslaught of admissions. The evening's theme: funniest beeper pages in the middle of the night.

"I once got this page from a nurse," said an intern. "`Doctor, your patient is covered in ants.'" The table erupted in laughter. Apparently, the patient had come in off the streets and brought the ants with him. They crawled out from their hiding spots after the doctor had done the initial workup. Another hilarious page: "Doctor, your patient is on fire." The man in question was psychiatrically unstable and had ignited himself. We were howling in between spoonfuls of ice cream.

[. . .]

In retrospect, I realized that during that night in the Moffiteria, I had, strictly speaking, violated a central tenet of the professionalism contract, which states: "I will treat patients and their families with respect and dignity, both in their presence and in discussions with other members of the health care team." We had been laughing at the patients and their misfortune. They were the butt of the joke, their dignity violated. But they were also the ultimate reason why I had endured the rigors of training thus far — and why staying up late studying had been a labor of love. In hindsight, laughing seemed a bit like betrayal.

Why, then, in those few seconds of juvenile hilarity, did I not feel an ounce of guilt? Perhaps it was simply that being with a group of other medical "professionals" made it seem okay. Or maybe it was justified because laughing brought us together as a team in an important bonding moment, which would ultimately benefit our patients. Or perhaps laughing was less about making fun of patients and more about coping, finding humor in a day filled with suffering. We were witnessing more darkness in our 20s than many other people see in a lifetime.

I matched!

(Here's what I mean by "matching.")


If you can hear the sound of my voice, have a drink
And a snack.

Would that I could give shalekhmones to everyone I know. Until that day, this Purim poem, included in every bag of raisins and hamentaschen, will have to do. (Yiddish and Hebrew versions here.)

Pain brings redemption
Unless it doesn’t.
Reason to celebrate
Isn’t Their defeat.
My survival’s not the why of it.

Proper partying has a drive
Unbound to past suffering,
Reactive but not visceral.
I say we get drunk now –
Maybe just a little bit.

Prepare a list of our demands.
Upthrusting sugar-sticky fists,
Rage against the Maker.
Importune the Deity for
Moral strength, lawful rigor, smooth-burning whiskey, tasty cookies.


Of Three or Four People
Yehuda Amichai

Of three or four people at dinner
You're always sat next to the nudnik
Forced to hear about the neighbor's overgrown garden,
The uncollected trash on the hills
Lit by the soft golden stone
Paid for by the extortionate taxes
Of the municipality
Of Jerusalem.

And people who left for fifteen minutes
Come back in thirty, when dinner is cold.

Of three or four people at dinner
One always finishes his soup
But feels it's rude to ask for more.
He stares into the bowl.
Within him: hunger. For soup,
For peace, for Biblical passion
Tamely modernized. For language
Common, tasty and cozy
Like this soup
Which can no longer be ladled out

Since it has been eaten already
By you, and the main course
Still unserved.


Morality, homosexuality, and halachah
Fumblings toward a thought or two, in pseudo-axiomatic form.

1.1. The issue of homosexuality within (or without) halachah can be viewed in many ways. One can start with the relevant halachot and work from them "towards" the sociological reality of homosexuality -- that is to say, in a strictly constructionist vein, find those heterim [legal allowances] which might make it possible for the acknowledgment of homosexuality (not homosexual behavior itself) to exist within a halachic community. This assumes that the halachot are applicable, and that moral considerations are either (a) only intra-halachic, i.e. generated by the halachic system, or (b) never applicable to the halachic system even when generated from without.

1.1.1. Halachot are generally applicable. To be a halachically observant Jew means that there is a very strong presumption that the halachah applies in the case at hand. What the halachah is in a given case -- i.e. how that is to be determined -- is very complicated from a general point of view, and I won't go into that here.

1.1.2. There are cases in which the halachah is not applicable. Whether there is a general formulation of all such cases is beyond the scope of this blog. There is an argument among the poskim [halachic decisors] whether every state of affairs can be addressed by halachah, or whether there are some states of affairs which are halachically irrelevant.

1.1.3. Moral considerations are important for determining whether halachah applies in a given case. In opposition to R. David Halivni, for example, I believe that our halachic predecessors (Chazal) did operate with explicit moral criteria. Many of these criteria are explicit (tikkun ha-olam, for one), while others are obscured by literary style. Thus we would not be the first to use moral criteria for evaluating halachah. Whether such "firstness" is relevant is another question.

1.1.4. How moral considerations and halachah interact is not simple. There are some cases in which the moral reality has changed from what was held true according to the halachah as it stands.

1.1.5. Such changes in moral reality do not always require halachic attention.

1.1.6. When large classes of people, by virtue of their wholly moral actions, are regarded as "extra-halachic," or sinners, this requires halachic attention.

1.1.7. Note that 1.1.6. does not apply to egalitarianism, which should be defended on other grounds.

1.1.7. "Halachic attention" entails, among other things, a deliberation whether the halachah as it stands is consonant with the moral reality that we know to be the case.

1.2. Similarly, one could start with the premise that homosexuality is immoral, either because (as noted above) halachic prohibitions establish such immorality by their very existence, or the immorality of homosexuality is a fact of the matter independent of halachah. (Rabbi Joel Roth makes use of both these arguments in his teshuvah.) By this account, halachah would serve either as a guarantor of (heterosexual) morality, or a bar to homosexual behavior which is ipso facto immoral.

2.1. Adult, loving, consensual homosexual relationships are to be morally valued, i.e. are the opposite of immoral.

2.1.1. One can quarrel with 2.1., but this is not a place to rehash the arguments made elsewhere against such spurious claims as the following: homosexuals weaken heterosexual marriage; homosexuals weaken a society's moral fiber; homosexuals are sexually perverse.

2.2. A considerable minority of Jews are gays and lesbians. By 1.1.6., since the halachah as it stands considers them as sinners, liberal poskim (to whom this discussion is confined) should consider the matter closely.

2.3. The halachic ramifications of homosexuality are many, but at the root lies the de-oraita (Torah-level) prohibition of "lying with a man [as one does with a woman]," i.e. anal sexual relations.

2.3.1. Sexual relations are at the heart of a loving, consensual, adult relationship. There are sexual acts proper to heterosexuals and there are those proper to homosexuals. And, of course, there are those which overlap.

2.3.2. The moral dissonance caused by the halachic prohibition of homosexuality does not extend merely to later outgrowths of the Torah's prohibition, i.e. to "recognizing" gay-and-lesbian couples, or the like. Rather, it goes to the very root of the matter, to the prohibition of "lying with a man as one does with a woman."

2.4. A morally based halachic change must take into account the prohibition of anal sex.


Why Johnny still smokes
Unhealthy behaviors and why we can't stop.

MEDICINE MENSCH: Nobody's Perfect
March 3, 2006

When it comes to our health, we can all be careless. Why do some of us keep smoking when we have relatives who died young from lung cancer and heart disease? Why do we eat like it's going out of style when New York is chock-full of obese diabetics? Why are so many Sabbath tables heavily laden with cholent and challah with nary a fruit or vegetable?

All these behaviors are hard to change; some are even addictive. There's also ample scientific proof that some of them are partially society's fault. It is attractive to smoke when cigarettes are made to seem glamorous. It is hard to eat a healthy diet when the nearest store with fresh fruits and vegetables is 25 blocks away, in the rich people's neighborhood. To take a more familiar example, more and more of us are sedentary and overweight — with the rest of society forced to pick up the slack.

But every year there are many people who stop smoking, and there are others who manage to lose weight, even when all outside factors are stacked against them. Conversely, many of us who keep smoking, drink to excess or eat unwisely aren't doing so under duress. No one is holding a gun to our heads.

What's the cause of our errors in judgment? I don't know. But there are some potential answers.

We don't know any better. Why would someone knowingly behave in a way that has negative consequences? By nature, people strive for the good, one could say, and self-damage is only committed out of ignorance. But after years of intensive health education financed by everyone from the feds to Philip Morris, it's hard to find the untroubled soul who still believes that Marlboros are the doctor's best friend or that obesity is not damaging. Our response to being (re-)informed about the harms of this or that consumption is not a surprised "Oh, really?" but a guilty headshake and a sorrowful "I know, I know! I should stop!" There are those cases — such as in the early years of the AIDS epidemic — in which education makes, or would have made, all the difference, but not when an unhealthful behavior like smoking, poor diet or lack of exercise is already deeply ingrained.

We don't like to think about risks. Many people ride their bikes without a helmet — not because they don't know that helmets prevent injury, and not because they're foolhardy, but because they don't think about it. No one likes to think about car accidents, least of all on a beautiful spring day with the wind in your hair as you fly through Central Park.

That's an oversimplification. We do think about some risks quite a bit: The press has been preoccupied with recent disclosures about the ineffectiveness of the low-fat diet and with the pandemic of influenza among birds. But to use an unpoetic word, we misprioritize. It's not bird flu or fatty foods that are to blame for some of the world's worst and most frequent health problems — it's unwise, widespread behaviors, the consequences of which are easily predictable.

We can't be helped. Somewhere between the naiveté I started with as a medical student (just smile and be friendly, and people will cooperate to make themselves healthy) and the desperation of the cynics ("If there's a problem, it must be the patient's fault") is a disquieting truth. There are some of us who make decisions that doctors would call the wrong ones. Then, when we are involved in a conversation about our own health, given all the information and opportunities we need and provided with dedicated staff, experts in their fields who want nothing more than to help us over the rough patches — then, finally . . . we make exactly the same unwise health decision we made in the first place. Given all the necessary data, we make a different decision than public-health workers would make on our behalf.

Maybe that's because of the reasons I already mentioned: We don't know about the scientific evidence, or we can't appreciate technical discussions of statistical risk. But maybe, in the final analysis, we just don't want to. In other words:

It's out of our hands. We would change, but we can't. Quit bothering us. I don't like to exercise. I enjoy my cigarette. No one likes to be nagged. The more we're talked down to about what we should and shouldn't do, the more difficult it is for someone well meaning to broach the topic — and the more unpleasant it is for us to think about our unwise behaviors in the privacy of our own room. We avoid the issues.

Information is not the cure-all. Educating us to understand the complexities of health risks requires a shift in thinking that could take a couple of generations to take hold. Sometimes our frustrations and defensiveness seem insurmountable. So two choices are left: give up or keep trying.

Not coincidentally, these are the same choices every health-care worker has when trying to help a patient. Obviously there's only one right choice that helps both parties. To keep trying doesn't mean success; it means that patient and doctor show up at least semi-regularly — with ears open and with the hope that, equidistant from their frustrations, lies an understanding of why the other behaves the way he does. If we listen to each other in the doctor's office, maybe we'll all make fewer mistakes. Or at least we'll better understand the mistakes we keep making.

In the next few installments of Medicine Mensch, Zack will complete his last rotation as a medical student, travel to China, and get his M.D. Ask him about anything, or tell him how he's wrong, by writing to doctor@forward.com.